Common Disorders

Achilles Tendonitis

The Achilles tendon is the largest tendon in
the human body. It is located at the back of the ankle joint and can be
felt as a large, cord-like structure attaching to the back of the foot.
Since tendons serve to attach muscles to bone, the Achilles tendon also
attaches the large calf muscles, the gastrocnemius and soleus, to the
back of the heel bone, the calcaneus.

The muscle
mass and strength of the gastrocnemius and soleus muscles are greater
than all of the other muscles of the lower leg combined. Therefore, the
pull of these muscles on the Achilles tendon is very large since these
muscles help balance the body while standing, push the body forward
during walking, spring the body forward during running, and spring the
body upward during jumping. Because of the large amount of stress which
the Achilles tendon is subjected to during running and jumping
activities, the Achilles tendon is prone to injury.

The most common form of injury to the Achilles tendon is called Achilles tendonitis,
which is an inflammatory condition causing pain in the Achilles tendon.
Achilles tendonitis generally occurs in people who are active in sports
activities. Types of sports that commonly are associated with Achilles
tendonitis are basketball, tennis, running, football, soccer,
volleyball and other running and jumping sports.

Achilles
tendonitis tends to occur more frequently in older athletes than in
younger athletes. As a person ages into their thirties and especially
into their forties and fifties, the ligaments and tendons of the body
tend to lose some of their stretchiness and are not as strong as
before. This predisposes older individuals who are active in running
and jumping activities, to tendon injuries such as Achilles tendinitis.
However, Achilles tendonitis can also occur in teenagers who are very
active in running and jumping sports.

Diagnosis

Achilles
tendonitis is diagnosed by a history and physical examination of the
patient who describes pain at the back of the ankle with walking and/or
running activities. The pain generally will be associated with an
increase in running or jumping intensity or frequency. It is also often
associated with a change from running in a thick heeled shoe to a thin
heeled shoe, such as going from training shoes to racing flats and/or
racing spikes in cross-country and/or track. The pain from Achilles
tendonitis is often so severe that running is impossible and even
walking is uncomfortable.

During the physical
examination, the podiatrist will feel and push lightly around the
Achilles tendon to see if it is tender or has any irregularities in its
surface. Achilles tendonitis may cause the tendon to be thickened in
areas, may cause swelling of the area around the tendon, and can even
feel like the tendon has a painful bump on it. In addition, the person
with Achilles tendonitis will limp while barefoot, but walk more
normally with heeled shoes on. X-rays are not helpful in diagnosing
Achilles tendonitis but may be taken to rule-out other pathology. MRI scans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.

Treatment

Achilles
tendonitis generally responds very well to conservative treatment as
long as it is diagnosed and treated early. Surgery is rarely indicated
unless the Achilles tendonitis is particularly severe and chronic, or
if the tendon has ruptured completely.

Initially,
the podiatrist may treat the Achilles tendonitis by putting heel lifts
into the patient's shoes. In addition, the patient may be asked to
avoid barefoot walking or walking in low-heeled shoes. Non-steroidal
anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin, Advil) and
naproxen (Naprosyn, Aleve) may also be prescribed to calm the
inflammatory process in the tendon. Icing may be suggested to help
decrease the inflammation and pain in the tendon. Stretching exercises
for the calf muscles may also be given to the patient to help loosen
the calf muscle and Achilles tendon so that the tendon is not under as
much stress during normal daily walking activities. The stretching
should not be done however if it causes pain in the Achilles tendon.

Initially,
the patient with Achilles tendonitis will be asked to modify their
activities to decrease their running and jumping activities and do
alternative physical activities, such as swimming, which don't put as
much stress on the Achilles tendon. As the tendon starts to feel
better, the podiatrist will allow a gradual return to normal running
and jumping activities. If normal return to activities is not possible
within a few weeks, then many times the podiatrist may additionally
prescribe physical therapy and/or functional foot orthotics
to help the tendon heal more rapidly. The foot orthotics generally are
used during both the sports activities and walking activities to allow
for more normal foot and Achilles tendon function. If the physician is
concerned about a partial tear of the tendon the patient may be placed
in a below the knee cast. It can take several weeks or even months for
the tendon to heal depending upon the severity of the injury to the
tendon. It is not uncommon for a patient to return to activities too
quickly and re-injure the tendon. Careful monitoring of a return to
full activity is important and the patient must have patience during
this period of time.